Final Hours Flashcards
1
Q
Common Clinical Changes in the final hours?
A
- mobility
- GI
- GU
- respiratory
- CVS
- neurologic
2
Q
Mobility: changes and care
A
- decrease in mobility
- PPS- bedrest, maximum assistance
⭕Turn at least 2x per shift
⭕Incident pain meds
⭕Braden scale
3
Q
GI: changes and care
A
- dysphagia
- ⬇ intake to no intake
- ⬇ appetite
❌Do not force fluid❌
⭕Oral care
4
Q
GU: changes and care
A
- ⬇ output
- incontinence
- retention
❗Foley catheter- should be for patients comfort not for nurse
⭕✔skin breakdown
⭕Change briefs c turn
5
Q
Respiratory: changes
A
- “death rattle”- noisy, moist breathing
- congestion d/t inability to clear up mucus
- ⬆ secretions
- changes in breathing patterns: cheyne-stokes, rapid shallow, agonal
6
Q
Respiratory changes: Breathing patterns
A
- cheyne-stokes- periods of apnea
- rapid shallow- when close to dying
- agonal
7
Q
Respiratory congestion: contributing factors
A
- infection, inflammation
- pulmonary embolus
- CHF, pulmonary edema
- dysphagia
- Fluid overload?
8
Q
Respiratory congestion: Intervention
A
- Raise HOB -45 degrees
- No suctioning
- pharmacologic intervention: scopolamine, glycopyrolate, atropine
9
Q
Respiratory congestion: Pharmacologic intervention
A
1) Scopolamine - (preferred)
2) Glycopyrolate
3) Atropine
10
Q
Scopolamine
A
- dilates bronchial smooth muscle
- ⬇ GI secretions
- ⬇ peristalsis
- SEDATION
- Urinary retention
11
Q
Atropine
A
- tachycardia
- dry, flushed skin
12
Q
Glycopyrolate
A
- less sedating
- longer duration
- not as effective as scopolamine
13
Q
CVS Changes
A
- ⬇BP
- rapid weak pulse
- arrhythmia
- cool, mottled skin starting from extremities
14
Q
Neurologic changes
A
- ⬇LOC
- Confusion
- Delirium
- “primitive” reflexes
15
Q
Primitive reflexes
A
- Rooting
- Grasping
- Sucking
